1346687126 NPI number — GHA AUTISM SUPPORTS

Table of content: (NPI 1346687126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346687126 NPI number — GHA AUTISM SUPPORTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GHA AUTISM SUPPORTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DURRETT HOME
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346687126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBEMARLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28002-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-982-9600
Provider Business Mailing Address Fax Number:
704-982-8155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 BLAKE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBEMARLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28001-9309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-982-9600
Provider Business Practice Location Address Fax Number:
704-982-8155
Provider Enumeration Date:
06/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
HARWOOD
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
704-982-9600

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320900000X , with the licence number: MHL084029 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3408844 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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